As I write these lines, I think about the survivors of war in Aleppo, Syria, enduring desperate conditions. What is it like to witness the destruction of homes, the world, history, and identity, and become refugees or displaced persons? How does this social suffering caused by war manifest itself in health and well-being?

My colleagues and I at Birzeit University, supported by discussions with Lebanese, Syrian, and Iraqi academics from the Faculty of Health Sciences at the American University of Beirut, have developed an understanding of the effects of war on health, grounded on the confluence of scientific evidence and our collective experience as Palestinian and Arab academics to understand, give meaning to, and document what happens to our lives in war when we are chronically subjected to a variety of forms of violence. Wars, ethnic conflicts, and political violence have become central public health problems. Death, disability, and injury are the more visible and more enumerable eff ects of political violence. However, other deleterious consequences of war and  conflict on the health and well-being of survivors are elusive, are difficult to count, and lack appropriate metrics. Yet this suffering related to war threatens health and well-being, and its alleviation is a public health responsibility. For the surviving civilians of the Arab region’s wars and conflicts, internal displacement, forced migration, and permanent terror and violence extending into their homes are important consequences of war that cannot be reduced to a mere matter of physical survival assistance and support. In addition, these war victims have lost the health protections embedded in their ways of life because of the destruction of their social, economic, and cultural worlds. War survivors are traumatized and experience severe insecurities, instability, uncertainties, deprivation, loss of dignity, and humiliation. They suffer from the wounds inside, which can dramatically affect the capacity to respond to and recover from trauma—and, ultimately, can be alleviated only by the reconstruction of social worlds and justice.

We observe everyone counting the dead, the injured, and the disabled, enumerating the destroyed homes and infrastructure. This is all necessary, but not sufficient. The dead do not suffer anymore. Our task in public health research is to uncover what violence does to people, to the survivors. We therefore recommend that the concept of health be reframed in a way that includes the deep, internal wounds of the survivors of political violence, beyond physical health.

We posit that the foundational concept of social suff ering, as this relates to the survivors of war, can help reframe health and unfold the pain of living in war. It overrides the biomedical framework, which does not take into account justice and the causes of causes, that is, the political domain; and we stress the limits of medications and therapies. We came to realize the importance of exposure to political violence over the life course. People can endure the social suff ering of war daily, and the cumulative exposure to political violence gradually transforms the wounds inside into disease and death.

We understood that we needed to place social suffering on an ease–disease continuum, because it connects health to indicators of well-being, quality of life, insecurity, and distress, among other manifestations of the ill health accompanying the traumas of war.

Survivors of war oscillate back and forth on this continuum, depending on degree, severity, and chronicity of violation as well as the resources available to assist them to recover: wealth, strength, cultural stability, and social support, among others. When we approach, welcome, or host the scores of traumatized war survivors from the Arab region’s wars and conflicts, let us not forget their social suffering, the invisible painful wounds inside.

Rita Giacaman, PharmD, MPhil

Institute of Community and Public Health,

Birzeit University, West Bank, Occupied Palestine

doi: 10.2105/AJPH.2016.303637